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PENUNTUN PEMBELAJARAN
TEKNIK MENILAI FOTO BNO - IVP
SISTEM UROGENITAL
FAKULTAS KEDOKTERAN
UNIVERSITAS HASANUDDIN
2016
SISTEM UROGENITALIA
INDIKASI
1.
2.
3.
4.
SISTEM UROGENITALIA
ACUAN
Persiapan: Membersihkan daerah abdomen dengan laxativa atau menggunakan enema
untuk mengeluarkan massa feses dari perut. Penderita juga diminta untuk tidak makan 812 jam sebelum dilakukan test ini
Prosedur : Untuk foto BNO, setelah melakukan fase persiapan, penderita langsung
menuju ke ruang foto untuk pengambilan foto abdomen.
Pada IVP, penderita berbaring dan dilakukan infus kontras media lewat pembuluh darah
vena di tangan. Kemudian foto akan dilakukan pada interval 0, 5 mnt, 10 mnt, dan 20
mnt. Interval 0 adalah saat kontras dimasukkan sevara intravena. Test ini selesai, bila
setelah 20 menit telah didapatkan gambar kedua ginjal, ureter dan vesica urinaria.
References :
1. Peacock WF. Urologic stone disease. In: Tintinalli JE, Krome RL, Ruiz E,
eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. McGrawHill; 1995:549-53.
2. Schneider RE. Genitourinary procedures. In: Roberts JR, Hedges JR,
eds. Clinical Procedures in Emergency Medicine. 3rd ed. WB Saunders
Co; 1998:978
DESKRIPSI KEGIATAN
Kegiatan
# 1. Pengantar
# 2. Bermain Peran Tanya
& Jawab
Waktu
2 menit
30 menit
Deskripsi
Pengantar
1. Mengatur posisi duduk mahasiswa
2. Seorang dosen memberikan contoh
bagaimana cara melakukan Pemerik-saan
dan penuilaian hasil foto BNO & IVP.
Mahasiswa
menyimak/
menga-mati
100 menit
1.
Mahasiswa
dibagi
menjadi
SISTEM UROGENITALIA
melakukan
pemeriksaan foto
secara
serempak
3.
4.
# 4. Curah Pendapat/
Diskusi
15 menit
pasangan
1. Curah Pendapat/Diskusi : Apa yang
dirasakan mudah? Apa yang sulit? .
2. Dosen menyimpulkan dengan
menjawab pertanyaan terakhir dan
memperjelas hal-hal yang masih belum
dimengerti
Total waktu
150 menit
SISTEM UROGENITALIA
PENUNTUN PEMBELAJARAN
TEHNIK MEMERIKSA DAN MENILAI HASIL
FOTO BNO DAN IVP
(digunakan oleh Peserta)
Beri nilai untuk setiap langkah klinik dengan menggunakan kriteria sebagai berikut:
1. Perlu perbaikan: langkah-langkah tidak dilakukan dengan benar dan atau tidak
sesuai urutannya, atau ada langkah yang tidak dilakukan.
2. Mampu: Langkah-langkah dilakukan dengan benar dan sesuai dengan urutannya,
tetapi tidak efisisen
3. Mahir: Langkah-langkah dilakukan dengan benar, sesuai dengan urutan daan
efisien.
TS Tidak Sesuai: Langkah tidak perlu dilakukan karena tidak sesuai dengan keadaan.
NO.
LANGKAH / KEGIATAN
PERSIAPAN
1.
Pasanglah foto pada light box
2.
Periksalah identitas pasien (Nama/umur) pada foto
3.
Periksalah ada tidaknya marker (R/L,D/S) pada foto
4.
Periksalah kondisi foto :
- mencakup T12 simphysis os pubis
- perhatikan faecal mass (berhubungan dengan persiapan
penderita)
MEMBACA DAN MENILAI HASIL FOTO BNO
5
Lakukan identifikasi contour ginjal, psoas line, dan tulangtulang
6.
Lakukan identifikasi ada tidaknya bayangan radiopak pada
lintasan traktus urinarius
7.
Tuliskanlah hasil pengamatan saudara
MEMBACA DAN MENILAI HASIL FOTO IVP
8.
Perhatikanlah bentuk, ukuran dan letak ginjal
9.
Perhatikanlah fungsi ekskresi & sekresi kedua ginjal
10
Perhatikanlah pelviocalyceal system kedua ginjal (apakah
ada tanda-tanda bendungan atau tidak)
11
Perhatikanlah bentuk, ukuran ureter dan apakah ada tandatanda bendungan
12.
Perhatikanlah keadaan vesica urinaria
13.
Tuliskanlah hasil pengamatan saudara.
KASUS
1
2
3
SISTEM UROGENITALIA
NEPHROLITHIASIS
Background: Passage of a urinary stone is the most common cause of acute
ureteral obstruction and affects as many as 12% of the population. The pain may
be some of the most severe pain that humans experience, and complications of
stone disease may result in severe infection; renal failure; or, in rare cases,
death.
Pathophysiology: In patients with stone disease, more than 1 of 3 general
mechanisms is likely to be active. These include the following: (1) the possible
presence or abundance of substances that promote crystal and stone formation;
(2) a possible relative lack of substances to inhibit crystal formation; and (3) a
possible excessive excretion or concentration of salts in the urine, which leads
to supersaturation of the crystallizing salt. The greater the degree of
supersaturation, the greater the rate of growth of the calculi.
Stasis or anatomic factors can also contribute to the development of stone
disease. These include ureteropelvic junction (UPJ) obstruction, horseshoe or
ectopic kidney, autosomal dominant polycystic kidney disease, and
vesicoureteral reflux. Calyceal diverticula, the result of anomalous budding of
the calyceal system, is also associated with stone disease. In 10-40% of
calyceal diverticula, stones are present. These range from a few large calculi to
many tiny seed calculi and to the microscopic milk of calcium.
Medullary sponge kidney is another common anatomic cause of renal calculi.
The pathologic process in medullary sponge kidney is renal tubular ectasia.
Calculi form in approximately 50% of patients. The calcifications form in the
medulla but frequently pass into the collecting system. They are usually bilateral
and diffuse, but they may also be unilateral or segmental. On intravenous
urography (IVU), pyramidal clusters of calculi within the dilated tubules
classically become obscured or appear enlarged after contrast material
surrounds them in the dilated tubules.
Calcium stones account for 75-85% of urinary stones. Approximately one half of
calcium stones are composed of a mixture of calcium oxalate and calcium
phosphate. They demonstrate intermediate fragility to extracorporeal shock
wave lithotripsy (ESWL). Approximately three eighths of calcium stones are
formed of only calcium oxalate dihydrate. These may be spiculated, dotted,
mulberry, or jackstone in appearance. Usually, these stones are fragile in
response to ESWL. The remaining one eighth of stones are composed of
calcium phosphate (apatite) or calcium monohydrate. These stones are the
densest and, consequently, the least responsive to ESWL.
Calcium stones have numerous causes. Approximately 85% of calcium stones
are idiopathic, or primary. Idiopathic hypercalciuria occurs in more than one half
of patients with calcium oxalate stones. Most causes of hypercalciuria are
absorptive. Increased absorption in individuals after a normal diet causes an
6
SISTEM UROGENITALIA
SISTEM UROGENITALIA
In the US: Renal calculi occur in 5-12% of the American population, and
they are bilateral in 10-15% of patients. The prevalence of urinary lithiasis
is as high as 2-3% in the general population.
Mortality/Morbidity:
SISTEM UROGENITALIA
Race: Urinary stones occur more often in white populations than in black
populations. They are also more prevalent in highly developed countries,
possibly as a result of a higher protein diet.
Sex: Males are at a greater risk than females, with a male-to-female ratio of 3:1
(except for struvite stones and in black populations).
Age: Stones are uncommon but not unknown in children. The peak age for
development is in persons aged 40-60 years.
Clinical Details: Acute ureteral obstruction by stone causes severe colicky
(intermittent) flank pain that can radiate throughout the groin, testicles, back, and
periumbilical region. Some patients with renal calculi may have no symptoms at
all.
Hematuria usually occurs. It can be intermittent or persistent and microscopic or
gross. However, as many as 10% of patients with acute stones may not have
hematuria.
Occasionally, recurrent infection may result in pyelonephritis or abscess. Stones
can result in renal scarring, damage, and renal failure.
Preferred Examination: The goals of imaging are to determine the presence of
stones within the urinary tract, evaluate for complications, estimate the likelihood
of stone passage, confirm stone passage, assess the stone burden, and
evaluate disease activity.
When acute flank pain suggests the passage of a urinary stone, many methods
of examination can be used. Often, conventional radiography is initially used to
screen for stones, bowel abnormalities, or free intra-abdominal air. Radiographs
can also be used to monitor the passage of visible stones.
IVU (excretory urography) provides important physiologic information regarding
the degree of obstruction. Ultrasonography (US) is useful in young or pregnant
patients and in patients allergic to iodinated contrast material. US is also helpful
in problem solving.
All of these methods have become less useful with the advent of more sensitive
SISTEM UROGENITALIA
Section 3 of 11
Appendicitis
Cholecystitis, Acute
Cholelithiasis
Colon, Diverticulitis
Crohn Disease
Duodenum, Ulcers
Epididymitis
Gastric Ulcer
Gout
Meckel Diverticulum
Midgut Volvulus
Nephrocalcinosis
Obstructive Uropathy, Acute
Ovarian Torsion
10
SISTEM UROGENITALIA
Section 4 of 11
Findings:
Conventional radiography
Conventional radiography is often performed as a preliminary examination in
patients with abdominal pain possibly resulting from urinary calculi. These
images should be obtained before contrast material is administered to prevent
obscuring calcifications within the collecting system or calyceal diverticula.
Conventional radiographs should include the entire urinary tract, and, often, 2
11
SISTEM UROGENITALIA
Stones are often found at key points of narrowing such as the UPJ, the
ureterovesical junction (UVJ), and the point at which the ureter crossing
the iliac vessels. An addition site is on the right side where the ureter
passes through the root of the mesentery.
Calcium stones as small as 1-2 mm can be seen. Cystine stones as small
as 3-4 mm may be depicted, but uric acid stones are usually not seen
unless they have become calcified.
An erect or posterior oblique radiograph obtained on the side of the
calcification may help in distinguishing urinary stones from extraurinary
calcifications. This view can also depict calcifications that are projected
over the sacrum or transverse processes on the frontal view.
Preinjection renal tomography may depict additional stones, and it can be
used to confirm the relationship of stones to the kidneys.
Because stones are more visible with a lower peak kilovoltage (kVp),
maintaining a maximum of 60-80 kVp is best, if possible. Larger patients
may require a higher peak kilovoltage for acceptable exposure and
scatter. In this situation, compression of the abdomen and collimation is
critical.
Mild bowel preparation may be helpful for increasing the sensitivity of
conventional radiography for small stones in patients undergoing
screening or follow-up observation for stones.
Typically, phleboliths are round or oval, and they may demonstrate a
central lucency. However, they are often difficult to distinguish from
ureteral calculi. Phleboliths in the pelvis are usually located lower than
and lateral to the ureter, but they overlap with the ureter. Because
gonadal veins parallel the upper ureters, contrast enhancement may be
needed to opacify the ureter and demonstrate the extraurinary location of
phleboliths in the gonadal veins.
Intravenous urography
IVU is useful for confirming the exact location of a stone within the urinary tract.
IVU depicts anatomic abnormalities such as dilated calyces, calyceal diverticula,
duplication, UPJ obstruction, retrocaval ureter, and others that may predispose
patients to stone formation or alter therapy. Because contrast agents can
obscure stones in the collecting system, scouting the entire urinary tract prior to
their administration is critical.
When an acute urinary stone is the primary consideration, compression may not
be used to increase sensitivity for detection of low-grade obstruction. A caveat is
that the contralateral kidney may have an abnormality that requires ureteric
12
SISTEM UROGENITALIA
CAT SCAN
Section 5 of 11
SISTEM UROGENITALIA
14
SISTEM UROGENITALIA
CT findings
CT may depict the following:
The amount of perinephric fluid is correlated with the degree of obstruction seen on
IVU, and as with the obstruction, the amount of fluid is correlated with the likelihood
of stone passage. Normal hyperattenuating renal pyramids sometimes are seen.
These indicate that significant obstruction is not present. However, this finding has
been seen with proven ureteral calculi and is often absent in patients without
stones. For this reason, the usefulness of IVU is limited. If contrast material is
administered, a delayed or hyperattenuating nephrogram may also be visible on CT
scans if the ureter has an obstruction.
Conventional radiography may be helpful in visualizing larger stones, once they are
identified on CT scans, to provide a baseline to follow passage of the stone. If
kidney, ureter, and bladder radiographs fail to depict the stone, CT may be needed
to follow its passage. Approximately 40-55% of stones are not visible on abdominal
radiographs. Almost no stones with attenuation values of less than 200 HU are
visible, and repeat CT scans are usually required if passage of the stone is to be
followed. Cystine and urate stones have an attenuation of 100-500 HU; calcium
stones usually demonstrate attenuation higher than 700 HU. Considerable overlap
exists in the CT attenuation values of calcium stones.
Degree of Confidence: Individual CT signs are associated with varying degrees of
confidence, as noted in CT findings above.
False Positives/Negatives: False-positive results are almost exclusively the result of
a phlebolith adjacent to the ureter. False-negative results are primarily due to
indinavir radiolucent stones and error. CT scans often suggest an alternative or
additional
15
SISTEM UROGENITALIA
16